Georgina Morley explains why, in the light of the nursing recruitment crisis, moral distress in the healthcare workforce must be taken more seriously
Data published last month by the Nursing and Midwifery Council showed that for the first time since 2013, more nurses and midwives left the profession than joined it. Two of the most cited reasons for leaving the register were working conditions – specifically poor staffing levels and high workloads – and disillusionment with the quality of care that nurses felt able to provide.
Such stark findings serve as a reminder, not just for politicians and policy makers about the effects of austerity and cuts to public spending on the nursing workforce, but also to many researchers whose primary interests, like mine, involve workforce issues. My research focus is on moral distress; one worrying effect reported in studies exploring the issue in the US is that nurses and doctors who report higher levels of moral distress are also considering leaving their position. If the same pattern emerges in the UK, then policy makers will have further reason to take this important issue seriously.
There are many different ways to understand moral distress, and much disagreement about how it should be understood. Suggestions vary, from the very narrow (which say moral distress is just psychological distress arising from not being able to carry out the action one thinks is morally correct) to broader definitions (which suggest moral distress occurs during moral uncertainty, moral conflicts and/or moral dilemmas).
My research suggests that moral distress occurs in response to a broad range of experiences, such as from uncertainty when faced with substantial ethical questions; for example, whether life-sustaining treatment should to be withdrawn from patients. This was seen during the recent debate around Charlie Gard and whether or not it was in his best interests to withdraw life-sustaining treatments or allow his parents to take him to the US for experimental treatment. There are also much ‘smaller’ questions about whether one should suction a patient under protest and when to carry out personal care.
My research interest in moral distress arose primarily through my own clinical experiences and an awareness that almost every clinical encounter involves ethics, such as whether I choose to believe a patient’s reports of pain; whose call bell I decide to answer first; and which elements of care I am forced to leave undone. These small relational judgements form part of nurses’ everyday work. The ethics of everyday clinical practice has been termed ‘microethics’.
Part of my research involves capturing both these smaller and larger ethical issues and understanding how these ethical experiences inform the concept of moral distress. It is through learning from nurses about their own experiences of ethics and decision-making that I aim to better understand what moral distress is, how it affects nurses working in the UK, and how we ought to respond to it.
I propose that the definition of moral distress should be broadened. This is important because the way in which we define and understand moral distress will have a significant impact on how we recognise it and how we respond to it.
Georgina Morley is a doctoral student in Bioethics, University of Bristol and critical care nurse, Barts Health Trust.